Journal List > Korean J Leg Med > v.43(3) > 1131910

TOOLS
Park, Lee, Choi, Yang, Park, Won, Lee, Kim, Choi, Lee, Kim, Kim, and Yu: Evaluation of the Usefulness of Cardiac Enzyme Analysis for the Diagnosis of Acute Myocardial Infarction in Postmortem Inspection
Original Article

Korean J Leg Med 2019;43(3):91-96.

Published online: 8 January 2019

DOI: https://doi.org/10.7580/kjlm.2019.43.3.91

Evaluation of the Usefulness of Cardiac Enzyme Analysis for the Diagnosis of Acute Myocardial Infarction in Postmortem Inspection

Jong-Pil Park1, Tak Su Lee2, Minsung Choi2, Kyung-moo Yang3, Jeongwoo Park2, Yujin Won2, Jongseok Lee2, Duk Hoon Kim2, Seung Gyu Choi2, Kyunghong Lee2, Jeong Hwan Kim2, Moa Kim2, Miyoung Yu4

1Department of Forensic Medicine, Yonsei University College of Medicine, Seoul, Korea

2Division of Forensic Medicine Investigation, National Forensic Service Seoul Institute, Seoul, Korea

3Medical Examiner's Office, National Forensic Service, Wonju, Korea

4Gyeonggi Nambu Provincial Police Agency, Suwon, Korea

Correspondence to Jong-Pil Park Department of Forensic Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2482 Fax: +82-2-362-0860 E-mail: parkjp@yuhs.ac

      Revised 26 June 20192 July 2019       Accepted 24 August 2019

Copyright © 2019 The Korean Society for Legal Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Acute myocardial infarction is one of the most common causes of unexpected deaths, but there are limitations to its diagnosis in postmortem inspection. In this study, we aimed to investigate the usefulness of cardiac marker analysis for the diagnosis of acute myocardial infarction in postmortem inspection. This study was conducted on 30 postmortem inspection cases conducted by the National Forensic Service from 2016 to 2018. Tests for three myocardial enzymes (myoglobin, creatinine kinase-MB, and cardiac troponin I) were performed in each case, and the relationships between enzyme levels, cause of death, and factors affecting the postmortem tests were analyzed. Cardiac enzyme concentrations were not significantly different between the heart disease group and other disease groups, and the false-positive rate was increased due to postmortem changes. Therefore, we can conclude that it is not appropriate to use cardiac enzyme analysis for the diagnosis of acute myocardial infarction in postmortem inspection.

Keywords: Myocardial infarction, Diagnosis, Postmortem changes, Troponin I

REFERENCES

1. Park JH, Na JY, Lee BW, et al. A statistical analysis on forensic autopsies performed in Korea in 2017. Korean J Leg Med. 2018; 42:111–25.
crossref
2. Palmiere C, Mangin P. Postmortem chemistry update part II. Int J Legal Med. 2012; 126:199–215.
crossref
3. Barberi C, van den Hondel KE. The use of cardiac troponin T (cTnT) in the postmortem diagnosis of acute myocardial infarction and sudden cardiac death: a systematic review. Forensic Sci Int. 2018; 292:27–38.
crossref
4. Burns J, Milroy CM, Hulewicz B, et al. Necropsy study of association between sudden death and cardiac enzymes. J Clin Pathol. 1992; 45:217–20.
crossref
5. Carvajal-Zarrabal O, Hayward-Jones PM, Nolasco-Hipolito C, et al. Use of cardiac injury markers in the postmortem diagnosis of sudden cardiac death. J Forensic Sci. 2017; 62:1332–5.
crossref
6. Palmiere C, Tettamanti C, Bonsignore A, et al. Cardiac troponins and NT-proBNP in the forensic setting: overview of sampling site, postmortem interval, cardiopulmonary resuscitation, and review of the literature. Forensic Sci Int. 2018; 282:211–8.
crossref
7. Rahimi R, Dahili ND, Anuar Zainun K, et al. Post mortem troponin T analysis in sudden death: is it useful? Malays J Pathol. 2018; 40:143–8.
8. Kim YJ, Ahn YW, Jo GR, et al. Usefulness of rapid test for cardiac troponin T in postmortem diagnosis of sudden cardiac death. Korean J Leg Med. 2008; 32:6–12.

Table 1.
Demographic characteristics and postmortem findings
Heart disease Others Total
No. of subjects 13 17 30
Age (yr)      
 Mean±SD 66.8±15.7 57.3±12.0 61.4±14.3
 Range 42-97 40-83 40-97
Sex      
 Male 8 12 20
 Female 5 5 10
PMI, hours      
 Mean±SD 2.7±0.6 3.6±2.1 3.1±1.6
 Range 2.1-3.7 1.3-8.1 1.3-8.1
Livor mortis      
 No 0 1 1
 Non-fixed 11 13 24
 Fixed 2 2 4
Rigor mortis      
 No 6 7 13
 Jaw and neck 0 2 2
 Elbow and knee 4 2 6
 Finger and toe 2 4 6
CPR      
 Done 8 7 15
 No 5 10 15

PMI, postmortem interval; CPR, cardiopulmonary resuscitation; SD, standard deviation.

Table 2.
Comparison of cardiac enzyme concentration between heart disease and others
Cardiac enzyme COD Mean ±SD (ng/mL) Median (IQR) (ng/mL) P-valuea)
Myoglobin Heart disease 2,539.4±1,427.6 2,801.8 (2,780.7) 0.750
  Others 2,430.0±1,559.8 3,144.7 (3,306.7)  
CK-MB Heart disease 55.4±82.0 27.5 (75.3) 0.934
  Others 55.3±77.1 26.7 (65.8)  
Troponin I Heart disease 10.6±27.7 0.64 (2.48) 0.281
  Others 1.2±2.6 0.12 (0.88)  

COD, cause of death; SD, standard deviation; IQR, interquartile range.

a) P-values were determined with use of the Mann-Whitney U test.

Table 3.
Comparison between heart disease and others according to the clinical cutoff value of cardiac enzymes
Cause of death, n (%) P-valuea)
Heart disease Others
Myoglobin Positive 13 (100) 17 (100) -
  Negative 0 (0) 0 (0)  
CK-MB Positive 11 (84.6) 14 (82.4) 1.000
  Negative 2 (15.4) 3 (17.6)  
Troponin I Positive 8 (61.5) 7 (41.2) 0.269
  Negative 5 (38.5) 10 (58.8)  

a) P-values for creatinine kinase-MB and troponin I were determined with use of Fisher's exact test and chi-square test, respectively.

Table 4.
Diagnostic usefulness change according to cutoff value of troponin I
Cutoff value (ng/mL) Sensitivity (%) Specificity (%) PPV (%) P-valuea)
0.3 61.5 58.8 53.3 0.269
0.4 61.5 70.6 61.5 0.078
0.5 61.5 76.5 66.7 0.035
0.6 53.8 76.5 63.6 0.132
0.7 46.2 76.5 60 0.255
0.8 46.2 76.5 60 0.255
0.9 38.5 76.5 55.6 0.433
1.0 38.5 76.5 55.6 0.433

PPV, positive predictive value.

a) P-values were determined with use of chi-square test or Fisher's exact test.

Table 5.
Variables analysis on postmortem cardiac enzyme concentration
Myoglobin (ng/mL) CK-MB (ng/mL) Troponin I (ng/mL)
Median (IQR) P-value Median (IQR) P-value Median (IQR) P-value
Age (correlation coefficient) -0.382 0.131 -0.338 0.185 -0.042 0.872
Sex   0.05   0.246   0.14
 Male 1,169.6 (2,763.8)   11.7 (80.1)   0.09 (0.33)  
 Female 3,938.0 (63.8)   45.7 (47.8)   0.47 (5.95)  
PMI (correlation coefficient) 0.774 0.003 0.449 0.143 0.186 0.562
Livor mortis   0.577   0.349   0.368
 No 3,811.4   39   0.47  
 Non-fixed 3,144.7 (3,393.5)   22.4 (67.0)   0.07 (0.85)  
 Fixed 3,260   174.9   1.46  
Rigor mortis   0.167   0.088   0.906
 No 584.9 (2,914.6)   26.7 (42.6)   0.07 (2.86)  
 Jaw and neck 2,704.4   25.4   0.29  
 Elbow and knee 2,282.4   9.4   0.37  
 Finger and toe 3,928.0 (1,018.6)   131.3 (204.3)   0.81 (2.34)  
CPR   0.492   0.626   0.591
 Done 3,144.7 (3,516.6)   26.7 (40.4)   0.12 (2.84)  
 No 2,958.5 (3,211.7)   28.7 (114.2)   0.16 (0.58)  

IQR, interquartile range; CK-MB, creatinine kinase-MB; PMI, postmortem interval; CPR, cardiopulmonary resuscitation.

P-values for age and PMI were determined with use of Spearman correlation.

P-values for sex and CPR were determined with use of the Mann-Whitney U test.

P-values for livor mortis and rigor mortis were determined with use of the Kruskal-Wallis test.

Table 6.
Cases which cause of death was confirmed
Case No. Sex Age (yr) PMI (hr) Livor mortis Rigor mortis CPR Myoglobin (ng/mL) CK-MB (ng/mL) Troponin I (ng/mL) Autopsy Cause of death
1 Male 40 2.4 Non-fixed Neck No 1,597.3 11.7 0.11 Done Chronic alcoholism
2 Female 56 8.1 Non-fixed No Done >3,938.0 46.9 10.74 Done Nontraumatic SAH
3 Male 83 <6 Non-fixed No Done 421.4 6.5 0.12 Done PTE
4 Male 56 6.9 Non-fixed Finger and toe No >3,938.0 152.4 0 No Hanging
5 Male 57 <8 Non-fixed No No 504.2 4.7 0.04 No Hanging
6 Female 66 4 No Jaw Done 3,811.4 39 0.47 No Hanging
7 Female 45 <12 Non-fixed Finger and toe No >3,938.0 110.1 1.41 No Hanging
8 Male 48 <12 Non-fixed Elbow and knee No 3,887 7.1 0.37 No CO intoxication

PMI, postmortem interval; CPR, cardiopulmonary resuscitation; SAH, subarachnoid hemorrhage; PTE, pulmonary thromboembolism.

TOOLS
Similar articles